Students at risk

Universities nationally are reporting increasing levels of psychological disturbance among students. On rare occasions, a student's level of disturbance, or disturbed behaviour, may pose a threat to their safety or that of others. The following offers University staff a set of guidelines to assist them in responding to students who may be considered ‘at risk’ in this context.

Such guidelines cannot be prescriptive: each individual and situation is different and may require a different approach. Inevitably, staff who are responding at the time have to make difficult judgments and tolerate a high level of anxiety. This information has been written by staff in the Counselling Service, and in the Brookes Union Advice Service, to provide a framework within which decisions can be made, and to indicate the sources of consultation and support that are available.

How do you know about the problem?

In this case, it is important to listen carefully to the student, clarify the nature of the problem and its urgency, and ascertain the type of help they are looking for.

It is useful to check whether the student is already seeing a GP, counsellor, psychiatrist etc. If so, you could suggest the student gets in touch with them; very anxious students may seek to enlist help from a variety of different sources and this can sometimes be counter-productive.

Be clear about the extent of support and level of confidentiality you can offer. (Ideally, issues of confidentiality should be discussed in your first meeting with students, rather than at a point of crisis.) Explore with the student the other options available to them, making sure that they know how to make an appointment if this is appropriate.

If you feel that the student needs to be seen urgently, you may want to contact the relevant service yourself to help them arrange an appointment.

In this situation, it is essential to have clear boundaries and resist being made to feel solely responsible for the student's welfare. You may need to be very firm about exactly what you can do, eg ‘I can help you sort out the academic side, but you need expert help from ... I will help you make an appointment if you like.’

If the student refuses to seek help despite your persuasion, there is probably little more that you can do. Higher education institutions are not in loco parentis; students are legally adults and cannot be compelled to seek help in any but extreme, emergency circumstances.

If you are anxious about a student's safety, you could talk through your concerns with a member of Student Welfare. As well as providing a second opinion about possible courses of action, such consultation enables you to share the burden of dealing with a stressful situation. You do not need to give the student's name.

This is clearly a sensitive situation; what you do will depend to a large extent on how well you know the student, and whether you feel able to approach them directly. Factors such as poor attendance, or a sudden deterioration in work, may give you an opportunity to speak to the student. Unexplained absence may indicate that there is a problem; students in difficulty often find it hard to ask for help.

You may suspect that a student's misuse of alcohol or illegal drugs is involved in putting them or others at risk. If the risk is immediate (ie an overdose or a drunken student behaving in a life-threatening way), the emergency services should be called. With an ongoing situation, whether or not you feel able to approach the student will depend in part on the factors outlined above. For further guidance, see the University Regulation E16 Substance Misuse Policy for Students (PDF).

A student behaving in a bizarre or disturbing way can create a great deal of disruption and anxiety. The safety of the individual and of those around them must always be paramount. Clearly if the student is breaking the law, causing a breach of the peace or threatening harm to themselves or others, the situation is urgent and the police should be called.

That said, there are sometimes situations where a student is behaving in a disturbing way, but other students and staff have to tolerate the anxiety and frustration of knowing that nothing can be done until either the student accepts help, or the situation has escalated into an emergency.

If other staff approach you about a student, you need to find out what they expect from you, and whether this is possible. Students who are at risk create a great deal of anxiety in staff and fellow-students, who may understandably want someone to ‘do something’ to make the problem go away. As this is rarely possible, it is important to avoid being driven into action by your own or others’ anxiety. Unless it is an emergency, a meeting of staff involved may be the best way to contain everyone's concerns and decide on what should be done. It may also be helpful to consult Student Welfare.

Fellow students may come to you because they are worried, angry, want to help, want the problem to go away or simply don't know what to do. It is important that their needs are recognised, as well as those of the student causing concern. It can be difficult to live with someone who is experiencing mental health problems or emotional disturbance. Fellow students need support as well as practical information, such as how to contact a duty doctor or emergency services.

Friends/flatmates may want you to intervene. You need to make it clear that help cannot be forced upon the student concerned – it is far better if friends can persuade them to make an appointment with a GP, counsellor or adviser. If the other students give permission, you could contact the individual and explain that they have been to see you (but they will have to cope with possible repercussions in the relationship). In some cases, you may have a legitimate reason to get in touch with the student about a routine matter, and as outlined above, disciplinary procedures can sometimes be used to encourage a student to seek help.

Sometimes students (or their parents) may ask if the ‘problem student’ can be moved. If they are living in University accommodation, students experiencing difficulties have the same tenancy rights as their flatmates, and it would be a breach of contract to evict them — even if it were morally acceptable to make a vulnerable person homeless.

Parents, other family members, friends etc sometimes make contact with staff to express concern about the welfare of a student. It is University policy not to give out any information about a student without their permission - even to parents or friends.

When a young student is in crisis it can be tempting to contact their parents. Unless the student gives permission, this is a breach of confidentiality. On rare occasions, involving the student's family might actually increase risk, rather than being helpful.

An understanding response, together with information about University procedures and support services, can do a great deal to reassure worried parents or friends. Where appropriate, a member of Student Welfare will speak to external enquirers (although they will not breach confidentiality by giving information about an individual student client).

How urgent is the problem?

How you respond to a student at risk will depend to a large extent on your assessment of the urgency of the situation. Safety of the individual concerned and those around them has to be a prime consideration. Inevitably, risk assessment relies on personal judgement, and this can sometimes feel very onerous. If in doubt, it is always better to call on professional help (police, GP) — although even the professionals are not infallible.

Emergencies

Situations where there is an immediate risk of harm to the student or others obviously require urgent intervention. For example:

Where a student has made an attempt on their life (eg taken an overdose), the immediate priority is to call an ambulance.

If a student is threatening violence to others the police should be called.

If a student is threatening to harm themselves and their behaviour suggests that they will carry this out, then a doctor or the police should be called.

Occasionally a student becomes seriously mentally ill or disturbed to the extent that they pose a threat to themselves or others. In these circumstances, certain sections of the Mental Health Act (1983) can be invoked in order to obtain compulsory admission to a psychiatric unit. Three people have to sign a Section Paper — an approved Mental Health Worker and two doctors.

If a student is showing signs of serious disturbance and you have concerns about their/others' safety, their GP should be contacted (or an on-call doctor if out of working hours). This gives you an opportunity to describe the behaviour that is causing concern, and to ask the doctor to visit the student. The doctor will be able to assess whether the student needs a compulsory admission, and arrange this if necessary. If the doctor does not feel that circumstances warrant compulsory admission, they may encourage the student to agree to a psychiatric assessment. How soon this can be arranged will depend on the severity of the situation. A psychiatric assessment may result in the student being admitted as a voluntary patient, being prescribed medication and/or being offered ongoing outpatient care.

Suicide and self harm

The death of a student causes grief and distress to people both within and beyond the University community. When death is a result of suicide, the distress may be even more widespread, and compounded with feelings of anger, guilt and a profound sense of helplessness: ‘Why didn't we know?’ ‘Couldn't we have done something?’ ‘Surely we could have prevented this?’ As they struggle to come to terms with what has happened, family or friends may blame the institution or members of staff. While understandable, this can be doubly distressing to people who are already shocked and upset. If a suicide occurs, it is important that everyone involved receives accurate information, an opportunity to talk through their feelings, and ongoing support.

While suicides are rare, attempted suicide occurs more frequently within the University community. This too generates a great deal of anxiety, distress and disturbance both in the individual ‘at risk’ and those around them. If a student has made an attempt on their own life, or is threatening to do so imminently, this is clearly an emergency and help should be sought at once, as described above. Suicide attempts should always be taken seriously, even where the level of physical harm involved is not considered dangerous. It is not helpful to think of a suicide attempt as ‘just a cry for help’ or ‘attention-seeking behaviour’; evidence suggests that most people who succeed at suicide have already made one or more previous attempts.

If a student talks about self harm or wanting to be dead, it is important to listen carefully to what they are saying and take their feelings seriously, even if you feel they are not currently at risk. Clearly there is a balance to be struck: many people from time to time wish they were dead, without seriously intending to kill themselves. However it is a myth that ‘people who talk about it don't do it’. If you are concerned about a student's suicidal thoughts, you may want to seek a second opinion as described above, and/or refer them to a counsellor or GP, who will be more experienced in risk assessment.

Ongoing ‘at risk’ situations

Emergencies are relatively rare, although with a population as large as Brookes' they are bound to occur from time to time. It is important to remember that in most of the situations described above, the student will either remain at university or return at some stage. Students admitted to hospital after an overdose, for example, are often discharged relatively quickly. Students admitted to a psychiatric unit may be allowed home for days or weekends before they are discharged. Doctors and psychiatric services have strict confidentiality policies which may mean that little information is passed on. This can be frustrating for fellow students and staff, who may be alarmed if a student suddenly appears when they were assumed to be safely in hospital. Friends, flatmates and staff may be involved in considerable ongoing support, as contact with the professionals may be brief and relatively infrequent.

There are also ongoing situations where it is clear that a student may be ‘at risk’ although not currently in crisis. One of the difficulties of managing such situations is the inevitable fear that they may develop into an emergency. Examples might be students who self harm (eg cutting or burning themselves); frequently abuse alcohol to dangerous levels; or manifest symptoms of an eating disorder.

Having been made aware of a problem like this, you need to gather more information, either from the student or whoever has told you. How long has the problem been going on? Has it become more serious? Are other aspects of the student's functioning affected? If the problem has continued for some time but has only just come to light, it is probably most helpful to encourage the student to speak to their GP or a counsellor. If things are clearly deteriorating it may still be most appropriate to encourage the student to seek help; it may also be useful to consult one of the support services to discuss a contingency plan, particularly if the student is unwilling to acknowledge the problem or be referred on.

Confidentiality

As stated above, it is University policy not to give out any information about a student without their permission.

Staff in the Counselling Service, and in the Brookes Union Advice Service, are bound by professional codes of ethics concerning confidentiality. Counsellors and advisers will not discuss a student, or pass on information about whether or not they have attended, without the student's permission.

Most other members of University staff are not bound by such a professional code, but it is likely that students will assume that conversations are private and that they are speaking in confidence. On a day-to-day basis, the breaches of confidence that cause distress to students and inhibit them talking openly with you are most likely to arise from casual chatting.

You need to be clear in your own mind about how you deal with information or concerns that students share with you, and where possible make this clear from the outset. If you need to refer on, or discuss the student's problems with another member of staff, you should explain this to the student and check that they have no objections. If they are anxious about you sharing information, you may be able to maintain confidentiality by seeking advice as an anonymous enquiry.

The professional code for counsellors allows them to consider breaching confidentiality in very exceptional circumstances, where there are good grounds for believing that a client is at serious risk of physical harm, or poses such a risk to others. This offers some guidance to other staff who may be dealing with students who are distressed and/or possibly at risk, although what constitutes good grounds is clearly a matter of personal judgement. If you need a second opinion urgently, you can contact staff in the Counselling Service, or seek medical advice as discussed above.

Debriefing

Risky situations arouse powerful emotions. Once the crisis is over, those concerned may be left with feelings of helplessness and frustration. There may be guilt (‘If only I'd done something different... ’) or anger with others (‘If only they'd listened to me/acted more quickly’) and/or with the student concerned. These and other feelings are understandable and largely inevitable.

It is important that everyone concerned in an ‘at risk’ situation has an opportunity to debrief: to talk about their feelings, to share information and to support each other. Staff involved in managing the situation may also need an opportunity to review the effectiveness of their procedures and actions, without attempting to apportion blame. Debriefing can be an opportunity to learn from what has happened in order to be better prepared in future.

Staff in the Counselling Service are willing to work on these issues with individuals or groups, and Student Welfare is also available for this type of support.

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